Applicant's Name________________________________________________________SSN/EIN________________________________

Applicant's Address____________________________________________________________________________________________
hereby declares under penalty of perjury that he/she is the lawful (owner/purchaser/lienholder) of the
following described motor vehicle and hereby makes application(s) for the following:
___________________________________________________________________________________________________________________________________

ORIGINAL CERTIFICATE OF TITLE  
                                    Evidence of Ownership______________________________________________________________________
SALVAGE CERTIFICATE OF TITLE                              MCO, Previous Title No. Registration, etc.

MEMORANDUM CERTIFICATE OF TITLE for Certificate of Title Number________________________________________________________________

    Applicant acquired said motor vehicle from previous owner   _______________________________________________________________
    
                        Address of previous owner               _______________________________________________________________
                        
						_______________________________________________________________

                        Dealer Permit #_________________________ Vendor # _________________________________________________________					

The following is a full statement of all liens on said motor vehicle. If no lien, state "none". If more than one lien,
attach statement of all additional liens.

Lienholder_________________________________________________________ Address________________________________________________________
___________________________________________________________________________________________________________________________________

Applicant states that Certificate of Title Number________________________has been________________________; that said motor
                                                                                 (lost,stolen, destroyed)                    
vehicle has not been sold or disposed of and no liens or incumbrances exist except as stated below.

The (vehicle/title) is in the possession of _______________________________________________________________________________________
						(lienholder, owner, etc.)
residing at _____________________________________________________________________________and that if said Certificate of
Title be hereby recovered by this applicant, same will be delivered to the Clerk of Courts for cancellation.
___________________________________________________________________________________________________________________________________
ODOMETER CERTIFICIATION
Federal and State laws require that you state the mileage in connection with transfer of ownership or applying for a
duplicate Certificate of Title. Failure to complete or providing false information may result in fines and/or imprisonment.
I (we) certify to the best of my (our) knowledge that the odometer now reads                   
and is actual mileage of the vehicle unless one of the following statements is checked:
 The mileage stated is in                                  The odometer reading is not actual mileage
excess of the mechanical limits.                                            WARNING - ODOMETER DISCREPANCY
___________________________________________________________________________________________________________________________________
   
VIN         ____________________________     BODY TYPE _____________________     MAKE _________________________

MODEL       ____________________________     YEAR __________________________     CONVERSION ___________________ 

Purchase Price $________________________     Trade in Amount $ _____________     Tax Base _____________________

Ohio Sales or Use Tax Paid $____________     Vendor Disc. $ ________________     Tax Remitted $ _______________

Condition of vehicle (check one only):   Sales Credit Amount $ _____________
Tax   Exemption:    Yes   Reason________________________________________________________________

___________________________________________________________________________________________________________________________________

WARNING! You are required by law to state the true selling price. A false statement is in violation of section 2921.13
of the Ohio Revised Code and is punishable by six months imprisonment and a fine of up to one thousand dollars or
both. All transfers are audited by the Department of Taxation. The seller and buyer must provide any information
requested by the Department of Taxation. The buyer may be assessed any additional tax found to be due.
___________________________________________________________________________________________________________________________________

Applicant's Signature_____________________________________________________________________________

Sworn to and subscribed in my presence by____________________this_______day of____________,19_____

My commission expires___________________________________________________, 19_____.

        (seal)     Clerk, Deputy Clerk of Courts - Notary______________________________________